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Obstetricia y
Abstract
For a pregnant woman, the diagnosis of a high-risk pregnancy threatens the course of the pregnancy and even
the woman’s own life. Management of these cases requires not only that professionals have appropriate technical
Key words: skills, but also that the woman is provided with the necessary tools to help her face a "complicated pregnancy"
High-risk-pregnancy. and accept the possible consequences. Therefore, it is necessary to address these problems under a compre-
Emotions. hensive perspective that ranges from the sociocultural features to the woman’s own attitude towards pregnancy.
Prematurity. We present 10 key points that should be taken into account by obstetricians caring for women with complicated
Antenatal diagnosis. pregnancies.
Resumen
El diagnóstico de riesgo durante el embarazo representa para la gestante una amenaza para el desarrollo del
Palabras clave: embarazo o incluso para su propia existencia. El manejo de estos casos precisa una adecuada formación técnica
de los profesionales, pero también es necesario ofrecer a la gestante herramientas que le ayuden a afrontar
Gestación de
la situación de “embarazo complicado” y a aceptar las posibles consecuencias. Resulta necesario abordar los
alto riesgo.
Emociones. problemas obstétricos bajo una perspectiva integral que incluya desde las dimensiones relacionadas con las
Prematuridad. condiciones socioculturales del entorno hasta su propia actitud ante la gestación. Presentamos en forma de
Diagnóstico decálogo los aspectos a incorporar por los equipos obstétricos encargados de la atención a las pacientes con
prenatal. gestaciones complejas.
Correspondencia:
Ernesto González-Mesa
Departamento de Especialidades Quirúrgicas,
Recibido: 09/09/2018 Bioquímica e Inmunología de la Universidad de
Aceptado: 15/01/2019 Málaga
Facultad de Medicina. Universidad de Málaga
González-Mesa E, Blasco-Alonso M. Towards a comprehensive perspective in the care of Boulevard Louis Pasteur 32
complicated pregnancies: 10 key points from a psychosocial perspective. Prog Obstet Ginecol 29071-Málaga
2019;62(2):107-111. DOI: 10.20960/j.pog.00176. e-mail: egonzalezmesa@uma.es
108 E. González-Mesa et al.
From the moment a woman becomes pregnant, mul- Very often, the patient will have to accept leaving her
tiple factors affect her emotional status (Fig. 1). In par- job, admission to hospital, and the need for treatment. In
ticular, the consequences of a diagnosis of a high-risk addition, she must prepare for the care of her child, who
pregnancy are very often a source of psychological ten- may by ill or have special needs. Therefore, her pregnancy
sion in that they represent a real threat for the course of will differ considerably from what she had imagined.
the pregnancy or even for the woman’s life. Occasionally, Addressing her problem by taking into account the
fear of the physical pain the condition involves and the positive aspects of professional care rather than focus-
disability arising from treatment and management proto- ing on the problem or probability of failure will make
cols are a major source of internal conflict, with the result the patient less vulnerable. In our experience, pregnant
that the interests of the patient and those of her child are women feel better when we consider them as requiring
contradictory. "special care" than when we describe them as having a
high-risk pregnancy.
ANTENATAL DIAGNOSIS
Second, correct performance of the test requires the the remainder of her pregnancy will depend largely on the
commitment of the whole team so that the patient and guidance from her obstetric team. She should be provided
her child have access to appropriate technical facilities, with resources that enable her to face her new status as a
the time necessary for examinations, and the ideal phys- "pregnant woman with special needs" and to prepare for
ical space in order to ensure respect for the patient’s a potentially poor perinatal outcome, understood in this
privacy, both when she undergoes the test and when case as the birth of a preterm baby.
she expresses her emotions after the diagnosis, which is The situation is different when the risk of preterm birth
sometimes made in the antenatal diagnosis unit. arises from early rupture of membranes, cervical insuffi-
Finally, it is worth pointing out that in any medical dis- ciency, or other irreversible conditions. These situations
cipline, the physician’s own prejudices and stereotypes generally involve long-term admission to hospital, proba-
will necessarily lead to erroneous categorization. Not all bly until the end of pregnancy, thus removing the woman’s
pregnant women follow the same thought paths, since control over her life. She is required to stop working, leave
not all experience the same emotions or have the same her home, and must often move to hospitals in other parts
degree of knowledge about their situation, with the result of the country. In addition, she may have other children
that it is necessary to provide information on an individ- who have to be cared for by relatives, friends, neighbors,
ual basis, even to the extent that we take particular care or even public institutions. These patients clearly con-
with the vocabulary we use. Moreover, the patient does stitute a particularly vulnerable group in psychological
not necessarily think in the same way as the professional terms, with the result that emotional support is essential
who is providing her with information; therefore, it is inap- throughout the process (1).
propriate for the health professional to impose his/her Aside from a situation that involves the patient being
criteria in the management of difficult cases, irrespective excluded from her normal life as a result of the compli-
of how objective these criteria may seem. cations, clinical management requires a complex balance
In our opinion, providing objective information does not between 2 therapeutic strategies that sometimes pull in
require the professional to be cold or inflexible. In this opposite directions (1,2): on the one hand, optimization
sense, it is worth pointing out that there is never only a of outcomes in terms of fetal health (avoiding, where
single alternative when a severe condition is diagnosed, possible, fetal infection and minimizing the effects of
and even less so when the alternative proposed is a ter- preterm birth and its sequelae); and, on the other, opti-
mination. Many patients request antenatal palliative care, mizing outcomes in terms of maternal health (reducing
which is based on company, support, information, and the risk of sepsis and preventing complications associat-
empathy from the attending professionals up to the time ed with treatment).
of the birth. Ambivalent feelings are therefore very common: the
patient wishes the pregnancy to end as soon as possible
and to avoid the birth of a preterm infant with potential
THE RISK OF PRETERM BIRTH sequelae (brain hemorrhage, respiratory distress, and
other problems). It is logical that the woman wants the
On most occasions when a medical, surgical, or obstetric pregnancy to finish as soon as possible, since, as we have
problem complicates pregnancy, a key danger to be man- seen, diagnosis involves a considerable degree of physical
aged is that of the risk of preterm birth. The spectrum of suffering owing to the need to remain in hospital, with
potential adverse physiological and functional outcomes continuous treatment and diagnostic tests. However, the
that can lead to neonatal death and severe morbidity pregnancy may have to be brought to a close at any time,
means that symptoms and problems pointing to prema- and many cases are considered emergencies in which a
ture labor can generate considerable stress and anxiety preterm birth is unavoidable (1-3).
in the patient. The patient and the medical team should manage any
A large number of pregnant women visit the emergency uncertainty about the duration of pregnancy (extremely
department with preterm contractions for which medical premature vs late), the approach to concluding the preg-
treatment could prevent labor and make it possible to nancy (elective vs emergency, cesarean vs vaginal), peri-
extend the pregnancy by days or weeks. In these patients, natal outcome (severe neonatal morbidity vs moderate
admission to hospital—where necessary—is usually short; neonatal morbidity), and long-term outcome (normal vs
therefore, training them to recognize specific symptoms special needs). This, together with a setting in which the
would enable them to return to their family environment patient has no control over her own body, places her in
and be followed up with regular outpatient visits. They one of the most stressful situations she can experience.
would therefore feel that they maintain some degree of The perinatal team should be aware of this and provide
control over their situation. Of course, the threat of a tools to manage the situation.
preterm birth is a turning point in the natural history of a Years of experience caring for women hospitalized
pregnancy and one at which the woman’s experience of because of complicated pregnancies has shown us the
need for the obstetric team to bear in mind the following 6. Appropriate level of information
10 points:
We believe that the patient should always know whether
we believe a situation is stable or not, or whether changes
1. The patient is the focus of the process are expected in the short or long term. We should insist
on the idea that the obstetric team is suitably prepared
The patient should be at the very center of the process. to act at any time, when necessary.
Both her and her child’s health must be the objectives on
which any action taken is based. Every attempt should
be made to avoid the problems generated as a result of 7. Boost confidence in the team
the multiple pressures of the health system or because of
the patient’s own personality or that of the team caring We should transmit to the patient our experience in the
for her. management of situations such as hers. Where possible, we
should provide data on the prevalence of her complication,
as well as our results, so that she knows what to expect
2. Gestational age is a continuum from the situation in terms of poor or favorable results.
Cognitive-behavioral orientation therapy includes 9. Know the context of the patient’s relationships
interventions aimed at enhancing skills that can help the
patient cope with the situation in which she finds herself. It is necessary to identify the person who accompanies
Training in relaxation, breathing techniques, self-instruc- the patient during admission in order to ensure the cor-
tion, and cognitive control are appropriate strategies for rect approach to her social and family situation and the
women with complicated pregnancies. support she is counting on. It is often more appropriate to
hold an initial interview with the patient alone. During this
interview and afterwards, we can learn about her environ-
4. Reinforcing messages ment in order to identify the person who can best sup-
port her. We can also determine which aspects the patient
Communication between professionals and the patient wishes to share and which she prefers to restrict to the
is essential at every point during pregnancy. However, it is private relationship between herself and her physician.
also important to transmit messages that stress the effort In addition, the patient will sometimes tell us whether
required to follow our indications. Thus, we give meaning she prefers to be accompanied when we provide her with
to the change occurring in the patient’s life and transmit information or whether she prefers the person accompa-
our admiration for the way in which she strives to prolong nying her to be informed only about specific aspects on a
the pregnancy. separate occasion.